77462739-Nclex-Study-Content-Use.doc

Heart Rates:Babies - Infants = 120-160 bpmToddlers = 90-140 bpmPreschoolers & School Aged = 75-110 bpmAdults & Teens = 60-100 bpm

On the ECG or EKG:P wave = atrial depolarizationP-R interval = represents atrial,AV node, & Purkinje depolarizationQ wave = septal depolarizationR wave = apical depolarizationS wave = depolarization of lateral wallsQRS complex = spread of excitation through the muscle of the venticlesT wave = ventricular repolarization

Starling's Law = the greater the strength of the myocardium as the ventricles fill with blood, the stronger the contraction.Cardiac output = the amount of blood that is pumped out of the LV each minute.The mitral valve is the most common site for vegetations.

ACE-I exert their effect by reducing preload.

Digitalis and related cardiac glycosides act by directly inhibiting the Na/K pump in the cell membranes.

After cardiac cath, monitor the person for bleeding &/or hematoma formation. Pulses are palpated distal to the site every 15 minutes for at least 1 hour, patient is on bedrest with lower extremities extended for at least 8 hours.

Acute blood loss (hemorrhage) is likely to cause sinus tachycardia.

When the heart rate increases with inspiration and decreases with expiration it is called sinus arrhythmia.

When someones heart "skips a beat" this is most times called premature atrial complex.

PVCs can lead into V-Fib

Verapamil reduces afterload and with concurrent use of nitroglycerine can cause ( increase ) hypotension.

Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure. Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP 24 hours

Very Long: ( Lantus ) Onset - 4-6 hoursPeak - NoneDuration - 24 hours continuous7 Rights of Medication Administration Right Drug Right Amount Right Route Right time Right patient Right approach

Right documentation

Medication Administration 2 ml= maximum volume of injection persite for IM medsKetorolac ( toradol ) for short term pain management. Do not give longer than 5 days.

60gtts = 1 tsp3 tsp = 1 Tbsp6 tsp = 1 ounce2 Tbsp = 1 ounce6 oz = 1 teacup8 oz = 1 glass8 oz = 1 cup

Diseases that can affect a drugs response are:- cardiac disease- gastrointestinal disease- liver disease- kidney disease

Anticholinergic agents cause Dry mouth, urinary retention and constipation.

Phenazopyridine (Pyridium)--Urine will appear orange.

Dexamethasone used to decrease cerebral edema and pressure.

Remember, when it comes to iron administration:

Iron supplements IM or IV----iron dextran(IV route is preferred) IM causes pain, skin staining, higherincidence of anaphylaxis Take oral supplements with meals ifexperience GI upset Then resume between meals for maxabsorption

Use straw if liquids are used

Diltiazin (Cardizem) a calcium-channel blocker, inhibits Ca++ transport in heart and vasculary muscle cells therefore inhibiting excitation and subsequent contraction.

Ace Inhibitors can cause hyperkalemia and chronic cough- pt's should not use salt substitutes because they are mostly made from K+ which will further increase the K+.

Tylenol = Liver toxic (no more than 4 g/day) Give Mucomyst for overdose. Whereas, Ibuprofen = kidney toxic .

Alkylating Agent: [ Cisplatin ( Platinol ) ] - used for lymphoma; myeloma; melanoma; osteosarcoma; cervical,ovarian,testicular,lung,esophageal,and prostate cancers. Cisplatin caauses nephrotoxicity and ototoxicity, ensure adequate hydration and give diuretics prior to therapy. Have client void every hour or insert foley before therapy. Assess for hearing loss/deficits.

Carbidopa/Levodopa ( Sinemet )- tx for Parkinson's, carbidopa prevents metabolism of levodopa and allows more levodopa for transport to brain. Levodopa ( Larodopa ) should be d/c'd 8 hours before statring Sinemet.

Bromocriptine ( Parlodel ) - tx of Parkinson's, amenorrhea, galactorrhea, female infertility, suppression of postpartum lactation, acromegaly.

Ropinirole ( Requip ) - tx of idiopathic Parkinson's disease.

Quinidine - give with food, monitor electrolytes, monitor liver and kidney function, encourage patient to report dizziness or faintness immediately.Used in a-fib and a-flutter.

Alprazolam ( Xanax )- antianxiety agent, usual dose is 0.25-0.5 mg two to three times daily. Side effects: drowsiness, dizziness, lethargy, confusion.

Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure. Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP 6)

NOTE: False K elevations are seen in hemolysis of samples!

Chloride (Cl):- Normal: 96- 106

* Reduced: by metabolic alkalosis* Increased: by metabolic or respiratory acidosis

Bicarbonate (HCO3):- Normal: 24- 30 - The test represents bicarbonate (the base form of the carbonic acid-bicarbonate buffer system)* Decreased: acidosis* Increased: alkalosis

GLUCOSE:Normal: 70- 110 * Hyperglycemia: s/sx: increase thirst, increase urination and increased hunger (3Ps). May progress to coma causes: include diabetes* Hypoglycemia: s/sx: sweating, hunger, anxiety, trembling, blurred vision, weakness, headache or altered mental status causes: fasting, insulin administration

BUN: Blood Urea Nitrogen- Normal: 8- 20 - Panic = > 100 mg/dl

Serum Creatinine (SCr):- Normal: 0.7- 1.5 for adults and 0.2- 0.7 for children - SCr is constant in patients with normal kidney function. * Increase: Indicates worsening renal function

Total Protein and Albumin:- Total protein: normal = 5.5- 9.0- Albumin: normal = 3.- 5 * Related to liver status* Low: Cause: liver dysfunction S/sx: peripheral edema, ascites, periorbital edema and pulmonary edema.

Serum Calcium (Ca):- Normal = 8.5- 10.8 * Hypocalcemia: less than 8.5 Causes: low serum proteins (most common), decreased intake, calcitonin, steroids, loop diuretics, high PO4, low Mg, hypoparathyroidism (common), renal failure, vitamin D deficiency (common), pancreatitis S/sx: fatigue, depression, memory loss, hallucinations and possible seizures or tetany Lead to: MI, cardiac arrhytmias and hypotension Early signs: finger numbness, tingling, burning of extremities and paresthias.

* Hypercalcemia: more than 10.8 Cause: malignancy or hyperparathyroidism (most common), excessive IV Ca salts, supplements, chronic immobilization, Pagets disease, sarcoidosis, hyperthyroidism, lithium, androgens, tamoxifen, estrogen, progesterone, excessive vit D or thyroid hormone. Acute (>14.5) s/sx: nausea, vomiting, dyspepsia and anorexia Severe s/sx: lethargy, psychosis, cerebellar ataxia and possibly coma or death Increased risk of digoxin toxicity

Phosphate (PO4):- Normal: 2.6- 4.5

Magnesium (Mg):- Normal: 1.5- 2.2 - Primarily eliminated by the kidney* Hypomagnesemia: less than 1.5 Causes: excessive losses from GI tract (diarrhea or vomiting) or kidneys (diuretics). Alcoholism may lead to low levels S/sx: weakness, muscle fasciculation with tremor, tetany, increased reflexes, personality changes, convulsions, psychosis, come and cardiac arrhythmia. * Hypermagnesemia: more than 2.2 Caueses: incrased intake in the presence of renal dysfunction (common), hepatitis and Addisons disease S/sx: at 2-5 mEq/L = bradycardia, flushing, sweating, N/V, low Caat 10-15 mEq/L = flaccid paralysis, EKG changesover 15 = respiratory distress and asystole.

Alkaline Phosphatase:- Normal: ranges vary widely- Group of enzymes found in the liver, bones, small intestine, kidneys, placenta and leukocytes (most activity from bones and liver)* Increased: occurs in liver dysfunction

Aminotransferases (ALT and AST):- ALT and AST are measure indicators of liver disease. Sensitive to hepatic inflammation and necrosis.- Increase: occurs after MI, muscle diseases and hemolysis.- Normal ALT: 3- 30

Direct Bilirubin (Conjugated):- Normal: 0.1-0.3 mg/d;* Increase: associated with increases in other liver enzymes and reflect liver disease

Urine:- Normal: should be clear yellow* Cloudy: results from urates (acid), phosphates (alkaline) or presence of RBC or WBC* Foam: from protein or bile acids in urine - Side note: some medications will change color of urine* Red-Orange: Pyridium, rifampin, senna, phenothiazines.* Blue-Green: Azo dyes, Elavil, methylene blue, Clorets abuse * Brown-Black: Cascara, chloroquine, senna, iron salts, Flagyl, sulfonoamides and nitrofurantoin

pH:- Normal: 4.5- 8

Protein content [in urine]:- Normal: 0 - +1 or less than 150 mg/day* Protein in urine: indication of hemolysis, high BP, UTI, fever, renal tubular damage, exercise, CHF, diabetic nephropathy, preeclampsia of pregnancy, multiple myeloma, nephrosis, lupus nephritis and others.

Microscopic analysis of Urine:- Urine should be sterile (no normal flora)- Few, if any, cells should be found- Significant bacteriuria is defined by an initial positive dipstick for leukocyte esterase or nitrites. If more than 1 or 2 species seen, contaminated specimen is likely.

Learn the Difference in IV Fluids Hypotonic solutions

0.45% Sodium Chloride (Osmolarity of 155, pH of 5.0 to 5.6) - replaces sodium, replaces chloride, and provides free water. Contains 77mEq of sodium and 77mEq of Chloride. Used most often to hydrate patients and to treat hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. When used continuously and exclusively, the patient needs to be monitored for hyponatremia and calorie depletion (there are no calories in this solution).

Isotonic solutions

2.5% Dextrose and 0.45% Sodium Chloride (Osmolarity of 280, pH of about 4.0 to 4.5) - provides calories and free water

5% Dextrose and 0.11% Sodium Chloride (Osmolarity of 290, pH of about 4.3) - provides calories and free water, provides some sodium and chloride

0.9% Sodium Chloride (Osmolarity of 308, pH of 5.7) - primarily used to replace sodium and chloride, treats hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. The reason for it's used with blood transfusion is because it will not hemolyze erythrocytes. Often given as rapid bolus for fluid replacement during resuscitation.

5% Dextrose and Water (Osmolarity of 253, pH of about 4.5 to 5.0) - provides calories and free water.

Normosol R [Abbott] (Osmolarity of 295, pH of 6.6) - provides electrolytes

Plasmalyte A [Baxter] (Osmolarity of 294, pH of 7.4) - provides electrolytes

Plasmalyte R [Baxter] (Osmolarity of 312, pH of 4.0 to 6.5) - provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis.

Isolyte E [McGaw] (Osmolarity of 315, pH of 6.0) - provides electrolytes

Ringer's (Osmolarity of 310, pH of 5.5 to 5.8) - it's content is very similar to plasma, but should not be used continuously since it contains no calories and could result in an excessive amount of one or more of the electrolytes it contains. It's components include sodium, chloride, potassium and calcium. It is used to replace electrolytes and to hydrate, often where there has been extracellular fluid loss. Adding Dextrose increases the osmolarity of the solution and lowers it's pH making it a hypertonic solution.

Lactated Ringer's [also known as Hartmann's solution] (Osmolarity of 275, pH of 6.5 to 6.6) - as with Ringer's, it's content is very similar to plasma, but should not be used continuously since it could result in an excessive amount of one or more of the electrolytes it contains. It's components include sodium, chloride, potassium, calcium and sodium lactate which is used to replace electrolytes and to hydrate, often used where there has been extracellular fluid loss. It is used in treating mild to moderate metabolic acidosis and hypovolemia. Often given as rapid bolus for fluid replacement during resuscitation. Since lactate is metabolized in the liver it shouldn't be used in patients with hepatic diseases. Using it in a patient with lactic acidosis will overload the person's buffering system. Adding Dextrose also increases the osmolarity of the solution and lowers it's pH making it a hypertonic solution.

2.5% Dextrose in half strength Lactated Ringer's (Osmolarity of 263, pH of 5.0) - provides calories and free water, provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis. Also see the information above with Lactated Ringers.

6% Dextran and 0.9% Sodium Chloride (Osmolarity of 308, pH of 4.0 to 4.5) - 6% Dextran is a high molecular weight solution. The NaCl replaces sodium and chloride. Treats hyperosmolar diabetes, metabolic alkalosis where there has been sodium depletion and fluid loss. It draws fluid into the vascular system. Dextran is a plasma expander that is given for shock or anticipated shock related to trauma, surgery, burns or hemorrhage, and for the prophylactic prevention of venous thrombosis and pulmonary embolism during surgery. It should NOT be used as a blood substitute except in emergencies when blood is not available. It's volume expansion effect lasts for approximately 24 hours during which the dextran is slowly broken down to glucose and metabolized into carbon dioxide and water. Complications with the use of this solution include anaphylactic reaction, wheezing, tightness in the chest, GI problems of nausea and vomiting, circulatory overload and tissue dehydration. If blood transfusion is intended, the type and cross match needs to be done before this solution is started. Because dextran pulls fluid into the vascular system it will result in altered blood tests.

10% Dextran and 0.9% Sodium Chloride (Osmolarity of 252, pH of 4.0 to 4.5) - 10% Dextran is a low molecular weight dextran. It is used in treating shock related to vascular system fluid losses such as in burns, trauma, hemorrhage and surgery. It is also used for the prophylactic prevention of venous thrombosis and pulmonary embolism during surgery. Complications include circulatory overload that results in various kinds of congestion and increased bleeding time. As with the 6% Dextran solutions, subsequent laboratory blood tests will be altered due to it entering the vascular system. This Dextran is excreted through the renal system within 24 hours.

Hypertonic Solutions

5% Dextrose and 0.2% Sodium Chloride (Osmolarity of 320, pH of 4.0 to 4.4) - provides calories and water, replaces sodium and chloride. This is given for fluid replacement.

5% Dextrose and 0.3% Sodium Chloride (Osmolarity of 365, pH of 4.0 to 4.4) - provides calories and water, replaces sodium and chloride



10% Dextrose and 0.2% Sodium Chloride (Osmolarity of 575, pH of 4.3) - provides calories and water, replaces sodium and chloride

10% Dextrose and 0.45% Sodium Chloride (Osmolarity of 660, pH of 4.3) - provides calories and water, replaces sodium and chloride

10% Dextrose and 0.9% Sodium Chloride (Osmolarity of 815, pH of 4.0 to 4.3) - provides calories and water, replaces sodium and chloride

3% Sodium Chloride (Osmolarity of 1030, pH of 5.0) - used to replace severe sodium and chloride losses. Other conditions it might be used for are excessive sweating, vomiting, renal impairment and excessive water intake where hyponatremia has occurred.

5% Sodium Chloride (Osmolarity of 1710, pH of 5.0 to 5.8) - used to replace severe sodium and chloride losses. Other conditions it might be used for are excessive sweating, vomiting, renal impairment and excessive water intake where hyponatremia has occurred.

10% Dextrose and Water (Osmolarity of 505, pH of 4.3 to 4.5) - provides calories and water

50% Dextrose and Water (Osmolarity of 2526, pH of 4.0 to 4.2) - provides calories and water

5% Dextrose in Ringer's (Osmolarity of 562, pH of 4.3) - provides calories and free water, provides electrolytes. Also see the information above with Ringer's

5% Dextrose in Lactated Ringer's (Osmolarity of 527, pH of 4.9) - provides calories and free water, provides electrolytes. Also contains sodium lactate which is used in treating mild to moderate metabolic acidosis. Also see the information above with Lactated Ringers.

5% Dextrose and 5% Alcohol (Osmolarity of 1114, pH of 4.5) - Provides calories and free water

5% Sodium Bicarbonate Injection (Osmolarity of 1190, pH of 8.0) - Is an alkalizing solution that is used to treat metabolic acidosis associated with renal disease and cardiac arrest. The sodium in the solution is an antagonist to the cardiac effects of potassium. It is also used in severe hyperkalemia. It maintains osmotic pressure and acid-base balance. The major complications associated with it's use are related to electrolytes and include metabolic alkalosis, hypocalcemia, hypokalemia, water and sodium retention that cause hypernatremia, other electrolyte imbalances and IV site extravasation that causes chemical cellulitis, necrosis, ulceration and sloughing of the skin.

1/6 M(olar) Sodium Lactate (Osmolarity of 335, pH of 6.5) - Contains sodium lactate which is used in treating mild to moderate metabolic acidosis.

10% Mannitol Injection (Osmolarity of 549, pH of 5.7) - Mannitol is a sugar alcohol colloid and a plasma expander. It promotes diuresis by drawing fluid from the cells into the plasma. It acts rapidly and is excreted within 3 hours through the kidneys. It is primarily used for intracranial pressure and cerebral edema where it acts within 15 minutes of being infused. It will also be used during the oliguric phase of acute renal failure to promote the excretion of toxic substances from the body. In high intraocular pressure, it pulls fluid from the anterior chamber of the eye within 30 to 60 minutes of infusion. Complications include frequent and severe fluid and electrolyte imbalances, cell dehydration, fluid overload, skin extravasation and necrosis with infiltration of the IV site, precipitate formation in the IV line and altered laboratory blood tests. The patient's blood tests should be monitored when the patient is receiving mannitol.



Basically

the Dextrose solutions also serve as diluents for the administration of many IV medications.

In general, the electrolyte solutions are isotonic. Adding Dextrose to them makes the resulting solution hypertonic.

Sodium deficits occur in head injuries, SIADH (Syndrome of Inappropriate Antidiuretic Hormone) and cirrhosis

I boldfaced the solutions with the lowest and highest osmolarity

Problems with using IV solutions of strictly Sodium Chloride include

hyponatremia (with continuous infusions of 0.45%)

calorie depletion

hypernatremia (with continuous infusion of the higher percentage NaCl solutions)

peripheral edema

an exhaustion of other body electrolytes

hyperchloremia

5% Dextrose in one liter of water contains 5 grams of dextrose per every 100mL which gives 170 calories per liter of fluid (this was a question on my state board exam in 1975).

Free water - The dextrose in IV solutions is metabolized very rapidly since it is a simple sugar which leaves behind plain old water. This water is able to cross all cell and tissue membranes to go into the various fluid compartments where is it needed.

The higher percentage Dextrose solutions are used to supply the patient with calories and often need to be given via a central IV line.

Hypovolemia occurs in acute pancreatitis. Always review your patient's laboratory tests to determine if the IV solution is appropriate, particularly

the BUN (blood urea nitrogen) - Normal: 10-20 mg/dl

serum creatinine - Normal: 0.7-1.5 mg/dl

hematocrit - Normal: 44-52% (male); 39-47% (female)

hemoglobin - Normal: 13.5-18.0 g/dL (male); 12.0-16.0 g/dL

serum osmolality - Normal: 280-295 mOsm/kg

serum electrolytes

sodium - Normal: 135-145 mEq/liter

potassium - Normal: 3.5-5.0 mEq/liter

chloride - Normal: 97-110 mEq/liter

calcium - Normal: 8.9-10.3 mg/dL, or 4.6-5.1 mEq/liter

magnesium - Normal: 1.3-2.1 mEq/liter, or 1.8-3.0 mg/dL

phosphate - Normal: 2.5-4.5 mg/dL, or 1.8-2.6 mEq/liter (adults); 4.0-7.0 mg/dL, or 2.3-4.1 mEq/liter (children)

arterial blood gasses for the

pH - Normal: 7.35-7.45

PaO2 - Normal: 80-100 mm Hg

PaCO2 - Normal: 38-42 mm Hg

bicarbonate - Normal: 22-26 mEq/liter

base excess - Normal: -2 to +2

Dehydration may also be called fluid volume deficit or hypovolemia and is due to:

excessive fluid and electrolyte losses from the extracellular compartment

loss of GI fluids due to vomiting, diarrhea, suctioning and fistulas

fluid lost through the skin as the body attempts to regulate it's temperature or trauma of the skin (burns, large open wounds, cuts).

loss of fluid through the renal system (these losses are usually excessive) by polyuria due to hyperglycemia, renal disorders, administration of osmotic diuretics, administration of concentrated IV solutions and tube feedings

hemorrhage which causes loss from the intracellular compartment

third spacing - the shift of fluid from the circulation to a space where it is trapped and cannot be exchanged with fluid in the extracellular space. There is no actual physical fluid loss but the involved fluid is basically "out of commission". This occurs in intestinal ileus

decreased fluid intake due to confusion, coma, very young age or very old age and not recognizing the sense of thirst 3 Ways to Prevent Missing Critical Changes in Your Patients Condition

Nurses-3 Ways to Prevent Missing Critical Changes in Your Patients Condition

Heres 3 ways you can prevent missing critical changes in your patients.

1. Follow the care plan until the problem is resolvedA few weeks ago, Bertie, on Coumadin for chronic atrial fibrillation, hit her forearm on a chair. Within hours her entire arm was edematous and ecchymotic. We suspected the bleeding was from her Coumadin dose being high. The PT/INR results proved we were right. Berties Coumadin dose was reduced. So far, so good. We wrote a nursing care plan stating the nurses needed to watch Berties forearm for edema, ecchymosis, pain, numbness or tingling or infection. Because the edema and ecchymosis were improving, did the nurses stop looking at Berties arm daily? Were we so focused on the current problem that we overlooked the new problem, a skin infection?

2. Set prioritiesDid the nurses get so busy that checking Berties arm was no longer a high priority? There are so many pressing tasks that must be done and so little time to do them. The interruptions seem endless at times. But do nurses always focus on whats most important? Do we delegate some things to other members of the nursing team so that we have time to perform important assessments of our patients?

3. Fine tune your assessment skillsIf you saw Berties forearm with a 10 cm by 6 cm area of erythema and edema, would you know to check for increased warmth? Would you call the NP, PA or physician to describe your findings? When you talked to the health care professional, would you mention Berties allergies and that she was on Coumadin so if an antibiotic was prescribed, the PT/INR could be checked more frequently? (Many antibiotics affect the blood levels of Coumadin.) Or would you just continue to monitor the site and pass this information on to the next shift?By following these three steps, you can lessen the chance that you will miss changes in your patients conditions. Read and follow your nursing care plans. Dont let yourself get so busy that the highest priorities get missed. Delegate tasks that other members of the nursing team can do. If you see an abnormality, dont just pass on the information, take action.

Nursing Interview Tips from a Recruiter

Nursing Interview Tips from a RecruiterMaking a lasting impression.

Diligently prepare and take your interview seriously. Heres her best advice from years of interviewing nurses:

1. Dress professionally.You may have a stellar resumeaced nursing school, received high marks on your NCLEX, hold great recommendationsbut if you come in as Sally or Sal Slop, your credibility will plunge. Steffel has had nurses arrive at interviews wearing shorts and flip-flops. Guess whether they got the job. Steffel recommends staying away from anything that will distract the interviewer from what youll bring to the organizationhiked-up hemlines, street attire, wrinkled slacks, flashy jewelry, disheveled hair, overpowering fragrances, or gum smacking. Since youre applying for a professional position, look the part: Keep it conservative, neat, and clean. First impressions are lasting.

2. Watch your non-verbal cues.According to Steffel, interviewers are looking for a nurse to be well composed and professional.They discern this through the nurses non-verbal cues. Dont forget interviewing fundamentals, like a firm handshake, a pleasant smile, direct eye contact, uncrossed arms, and an energetic tone of voice. Aside from displaying enthusiasm and sharpness, these gestures also reveal how you will interact with future customers (patients). And your poise points to how you will handle the countless unfamiliar and frightening scenarios a nurse faces during his/her career. In short,interviewers appraise your non-verbal communication as much as your verbal communication.

3. Exude enthusiasm.When Steffel interviews nurses, she also looks for a passion for the profession and the organization for which the nurse is applying. Steffel knows people are nervous and might occasionally flounder for wordsthats expected. Still, nurses should demonstrate excitement about their careers, that they have something unique to offer, and that they are fond of the organization for a specific reason (i.e., their mission statement or theyre a magnet hospital). Engaging the interviewer in conversation about the organization, also demonstrates your eagerness and ability to interact with people (which nursing is all about). While you may not have years of experience to buttress your credibility, your excitement and interest in the organization will do so.

4. Turn off your phone.In a world in which we are constantly reminded to turn off our cell phones and pagers, you would think it would be a no-brainer to do so before a job interview.Interviewers are fully present for the interview, says Steffel. The candidate needs to abide by those same principles.

5. Research the organization.Be prepared to answer the questions: Why are you interested in our organization? What brings you here? Why do you want to work at this hospital? And dont say, Because its the closest to where I live. Take time to review the hospitals mission statement, read articles written about the hospital, or review the job postingfind any information you can about the hospital and study it. It will be invaluable information during your interview.

For instance, if you researched Edward Hospital, where Steffel is a recruiter, youd find its a magnet hospital and about their brand promise to deliver care for people who dont like hospitals. During the interview, use information like this to demonstrate your interest in the organization. But dont simply say, I want to be hired because I want to be at a magnet hospital. Take it a step further, Steffel recommends, and explain why you want to be at a magnet hospital: because of the nurse support, the preceptor program, the internship, the transition training program, etc. This attention to detail shows the interviewer how serious you are about the position you are vying for.

6. Ask the right questions.Youre interviewing the organization just as much as were interviewing you, says Steffel, so you need to have questions prepared. Maybe there was something that the interviewer said during the interview that youd like to be clarified. Dont hesitate to ask. Now is the time to find out what wont work for your personalityrather than later, once youve signed the dotted line.

Questions nurses should ask include the following:

What is your orientation program like? Do you have a preceptor program? What is its duration? Do you allow time off for and/or pay for continuing ed? Do you have nurse educators, and how often are they available? How are performance evaluations done, and how frequently? Will I have to work weekends and holidays? Will I be on call? What is your retirement plan like? Will you contribute?

Preparation at every level will set you apart from your competitionand may help you evenenjoy the process.Read more Managing Your Career articles

www.seasonedrn.comGoals of New Recommendations "The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas," write Naomi P. O'Grady, MD, from the National Institutes of Health in Bethesda, Maryland, and colleagues from HICPAC. "Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies."The new recommendations are addressed to healthcare personnel responsible for intravascular catheter insertion as well as those involved in surveillance and containment of infections in hospital, outpatient, and home healthcare settings.Multidisciplinary strategies and topics addressed in the updated guidelines include education, training, and staffing; selection of catheters and sites; peripheral catheters and midline catheters; central venous catheters (CVCs); hand hygiene and aseptic technique; maximal sterile barrier precautions; skin preparation; catheter site dressing regimens; patient cleansing; catheter securement devices; antimicrobial/antiseptic impregnated catheters and cuffs; systemic antibiotic prophylaxis; antibiotic/antiseptic ointments; antibiotic lock prophylaxis, antimicrobial catheter flush and catheter lock prophylaxis; anticoagulants; replacement of peripheral and midline catheters; replacement of CVCs, including peripherally inserted central catheters (PICCs) and hemodialysis catheters; umbilical catheters; peripheral arterial catheters and pressure-monitoring devices for adult and pediatric patients; replacement of administration sets; needleless intravascular catheter systems; and performance improvement.

Recommendations Some of the specific recommendations include the following:

For peripheral and midline catheters, an upper-extremity site is preferred in adults. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used.

Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.

When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or PICC is preferred to a short peripheral catheter.

The catheter insertion site should be evaluated daily, and peripheral venous catheters should be removed if signs of phlebitis develop.

Risks and benefits of a central venous device to reduce infectious complications should be weighed against the risk for mechanical complications.

In adult patients, use of the femoral vein for central venous access should be avoided. For nontunneled CVC placement, a subclavian site is preferred to a jugular or a femoral site. To avoid subclavian vein stenosis, the subclavian site should be avoided in hemodialysis patients and patients with advanced kidney disease.

For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access for dialysis should be used.

Ultrasound guidance by those fully trained in its technique should be used to place CVCs.

A CVC should have the minimal number of ports or lumens essential for patient treatment.

Any intravascular catheter that is no longer essential should be promptly removed.

When adherence to aseptic technique cannot be ensured, such as for catheters inserted during a medical emergency, the catheter should be replaced as soon as possible (within 48 hours).

Systemic antimicrobial prophylaxis before insertion or during use of an intravascular catheter is not routinely recommended to prevent catheter colonization or CRBSI. Calculating Drug Dosages and Self-Test

http://www.testandcalc.com/quiz/testiv.htmhttp://www.dosagehelp.com/ is a phenomenal site. It helped me pass my tests with 100%, which is what is required to pass dose calc at my school.

How to document disasters

"If you didn't write it, you didn't do it." That may be the oldest and most tired clich in all of EMS and it is not exactly true. Likewise, "paint a picture & tell a story," is another biggie in documentation classes. I happen to agree with that one; unfortunately many providers are painting the wrong picture and telling the wrong story because they are not thinking about their audience. They are not considering who will be reading their report and why. Not to worry. I can fix it.Contrary to popular belief, patient care reports are not created for the singular purpose of feeding the voracious appetites of greedy lawyers. However, at feeding time, lousy documentation and your career make for a nice meal and there are plenty of sharks eager to take a big bite out of your assets.

Know your audience Like every call, every report is unique. There is a specific series of events (or non-events) that must somehow be recorded in a way that both shows and tells the reader what happened, and clearly describes your reaction to it. At the same time, for better or worse, the reader will gather some insight about your appreciation of the circumstances that brought you to the scene, your assessment of everything, your understanding of associated protocols, and your application of technique. That is a boatload of information for one narrative and how you communicate it will depend on who will be reading it, and why.

For example, the narrative for a fatal gunshot wound to the head that is left on scene for the medical examiner will look entirely different than that of a gunshot to the head that is transported and later dies. While the outcome is the same, the audience is different and thus the documentation is different.

Patient transports First and foremost, for patients who are transported, patient care reports are generated so future caregivers can know what happened before the patient came to them. The information is used to diagnose or rule out medical conditions; to identify medications taken and known drug allergies so as to prevent lethal combinations or anaphylactic nightmares; to guide advanced clinical assessments and treatment modalities, and the list goes on. If your prehospital documentation is inaccurate or incomplete, the easily avoidable can become an irreversible tragedy in the blink of an eye.

The BIG Five 1) Write for Doctors, Nurses, and Allied Professionals 2) Organize as if the patient will become unconscious and unable to provide any information 3) Assume that the person reading your report knows nothing about anything that happened before the patient arrived in the ED 4) Make sure the reader knows WHEN you did what you did 5) Presume nothing and leave nothing [relevant] to the imagination

Death in the field Then there is the issue of death in the field. Most systems have protocols that allow providers to withhold treatment and transport for the obviously dead. When called upon to document death in the field, you are not writing for the sake of future care, you are writing for medical examiners, homicide investigators, and possibly even criminal prosecutors (and criminal defense attorneys). While dead men tell no tales, your death-in-the-field documentation will speak volumes about what did or didn't happen; why that poor unfortunate is no longer an active participant in the game of life and whether you could have or should have done something about it.

The BIG Five 1) Write for medical examiners, homicide detectives, and criminal justice attorneys 2) Organize as if you expect to see the report projected onto a giant screen in a courtroom 3) Assume that the person reading your report knows nothing about anything that happened while you were on the scene 4) Make sure the reader knows WHY you didn't treat or transport 5) Presume nothing and leave nothing [relevant] to the imagination

Patients not transported As I have said and continue to say, the calls in which there is a patient who refuses treatment and transport are the most dangerous calls of all. There are times when a patient refusal is acceptable, but the fact remains that the audience for your documentation is most likely to be a lawyer who wants something from you because something bad happened after you left.

The BIG Five 1) Write for the Attorney who is suing you over this call (sad, but true) 2) Organize as if you expect to see the report projected onto a giant screen in a courtroom because it will be 3) Assume that the person reading your report (and the jury) knows nothing about anything that happened while you were on the scene 4) Make the reader understand WHY you didn't treat or transport 5) Presume nothing and leave nothing [relevant] to the imagination

As you can see, knowing the audience for your documentation is as important as everything else an emergency provider has to do, perhaps more so if knowing the audience leads to greater diligence and better care.

http://www.ems1.com/Columnists/david...s/david-givot/It's Grad Time ~ 6 things your preceptor never wants to hear

Contrary to nursing legend, preceptors arent villains. They want you to succeed, and, if given the chance, could be your best advocate. After all, most of them have volunteered for the job or have been identified by their manager as the type of person who would be able to help you best. When preceptor-new nurse relationships get to the point of intervention, its not always the preceptors fault . . . really. Sometimes, new nurses shut out their preceptor, saying things that demonstrate they dont want help, dont need help, or dont want to work at all.

Kim Rapper, RN, a preceptor for many years, tells you what not to say to your preceptor so that your relationship stays healthy and beneficial to you:

1. I already know how to do that.The know-it-all attitudeand cutting off your preceptor in the midst of instructionwill keep you from learning all you can. You dont know it all, not even the most seasoned nurse does. Even if youve seen a procedure done 102 times, you can benefit from the reiteration. Every preceptor, even if his/her personality drives you crazy, has insights from which you can benefit. And if you listen and watch closely, you may pick up some simple strategy to master the skills you already possess. So, dont shut your preceptor out, and be open to new ways of doing things.

2. I cant do this!Most preceptors appreciate when a new nurse admits they dont know how to do something. But dont say, I cant. Its not the right word, because you will be doing it by the end of the orientation. Saying I cant suggests you dont care to learn.

Instead, say, I dont know how to do this yet. I need your help. This demonstrates a willingness to learn. And it is completely appropriate; your preceptor needs to be in the room watching, helping, and coaching. No one should be doing something they feel they cant do or have never done before. Its in those instances that a good preceptor will be able to push youso, ultimately, you will be able to fly on your own.

3. Did you hear what so-and-so said?Cattiness and gossip are never appropriate. Its okay for a nurse to say to a preceptor, I dont feel comfortable with so-and-so nurse. But to come out and say things like, Did you hear what so-and-so did? chips away at your professional demeanor. Dont get me wrong, its okay for there to be differences. However, when your priority shifts from quality patient care to the Whos Who network, there is a problem. New nurses need to be socialized appropriately, and many preceptors take on that responsibility by inviting new nurses out to lunch and introducing them to the physicians. This needs to happen more frequently. If preceptors dont socialize new nurses into their peer group in a professional manner, then cattiness takes over.

4. If you dont put me on the day shift, Im going to quit!We had a new graduate make this demand. And, as you know, its an unrealistic one. New nurses are low on the totem pole, so expect to work the hard shifts. Most new grads start on the night shift; day shifts come with seniority. When you sign a contract, youre agreeing to work any shift. So its shocking to me that new grads start making demands when this is what theyve signed up for. However, if you are struggling with the night shift, seek support and advice from your preceptor on how to make nights work for the short-term; shes been there. Also remember that if you want to pick and choose your shifts, you have to stick with your hospital. At many hospitals, seniority is rewarded. Thats why Ive stayed with the hospital I started with; now, more often than not, I get the shifts I request.

5. Id rather be doingOnce I heard a new grad frequently and freely talk about changing her careerbecause nursing was beneath her aspirations. If nursing isnt what you expected, youve got to discuss that with your preceptor. But dont waste your time, or your preceptors time, if you know youre not going to stick with it. Nursing demands passion and a stick-with-it attitude.

6. Im doing it just for the money.These types are called appliance nurses. I made a commitment to myself when I was in nursing school that I would never keep doing this if it became just a job. That may not be something that everyone can do. But if you find you are seeing your job just as a paycheck, then maybe you need to take a step back. That may mean dumping some of your expectations of yourself. Or maybe you need to pursue activities that recharge you. For instance, I dabble in graphic arts, which rejuvenates me. When I go back to work, I do my nursing job much better because I want to, not because Im locked in. Ive learned you need to be able to do this job for the right reasons: to give the best possible patient care and make a difference in peoples lives.

http://www.realityrn.com/browse/more...es/precepting/[NEW] 2010 Guidelines CPR & ECC

http://www.heart.org/idc/groups/hear...ucm_317350.pdf

No longer A irway B reathing C irculation ...it's now C A B with emphasis on compressions FIRST, i. e. no longer Look, Listen, Feel prior to compressions.

So, Push Hard [at least 2"] & Push Fast [at least 100 x's/min].

Port-a-Caths ~ Use, Care, Accessing and Deaccessing

Accessing the Implanted Port -To be done weekly if accessed, or monthly for routine maintenance

1. Assemble Supplies Betadine swabsticks Alcohol swabsticks Masks Sterile gloves Huber needle Prefilled 10 NSS syringe Prefilled 5 Heparin syringe 2 x 2 gauze

2. Wash hands with soap and water

3. Peel open one corner of the Huber needle package only; Extend end of extension tubing only out the opening

4. Attach 10cc NSS syringe to extension tube.

5. Prime tubing and needle with NSS

6. Place Huber needle package on a secure flat surface and peel back package open.

Do NOT touch Huber needle until sterile gloves are on

7. Caregiver applies mask; the patient has the option of putting on a mask or turning their head away from the port area

8. Put on sterile gloves

9. Open alcohol swabsticks; prep site from center of port and work outward in a circular motion to include a 2-3 area; repeat using all three swabsticks

10. Allow alcohol to air dry and then repeat procedure with three Betadineswabsticks

11. Pick up Huber needle with NSS syringe attached; touch only the Huber needle as this is sterile and the syringe is not.

12. Fold wings of Huber needle back and hold securely; remove clear protective sheath from the needle.

PORT ACCESSING AND FLUSHING PROCEDURE

13. Locate and stabilize the port site with your thumb and index finger; creating a V shape.

14. Access the port by inserting the Huber needle at a 90 angle into the reservoir

15. Once accessed, the needle must not be twisted; excessive twisting will cut the septum and create a drug leakage path16. Flush the port with 2-5cc NSS and then attempt to aspirate a blood return; this confirms proper placement;

Do NOT aspirate an arterial port

17. Slowly inject the remaining 10cc NSS; observe for resistance, swelling or discomfort; if present, assess needle placement; if still present, remove the Huber and re-access or call the physician.

18. If this is a routine maintenance flush, close clamp, remove empty NSS syringe and attach Heparin filled syringe;

Do NOT attempt to aspirate blood with the Heparin syringe

19. Flush with 5cc Heparin and close the clamp

20. Secure the port with your thumb and forefinger and pull the Huber needle straight out

21. Hold slight pressure with a 2 x 2 until bleeding, if any, stops; there should never be excessive bleeding

22. This procedure should be done every 4 weeks if port is not used

Dressing the Port Site

1. If port is being used for continuous infusion, connect IV tubing after step 17 of the accessing procedure; if port is being used for intermittent infusion, apply clave clamp after step 19 of the accessing procedure

2. Port should be redressed once a week with needle change

3. Assemble Supplies

CVC dressing kit

Flat clean work surface

4. Wash hands with soap and water

5. Remove old dressing and deaccess port

6. Access port using the procedure described in A.

7. Open the package of 2 x 2s if extra padding is needed

8. Place one 2 x 2 under the wings to provide padding on the skin if Huber is not flush with chest

9. Tear a piece of Durapore tape approximately 3

long; split tape lengthwise; tape over Huber wings in a X format10. Cover site with Tegaderm; this provides an occlusive dressing and allows the patient to bathe or shower without disturbing the dressing

11. Secure the extra tubing with tape to prevent catching on clothes

http://www.horizonhealthcareservices...ort_access.pdf

Different Types of Hubers:

The new GRIPPER PLUS Safety Needle is used to deliver medications intravenously through a patient's implanted port. Its unique feature is a safety arm that is lifted to lock the needle into a protected position when de-accessing it from an implanted port. An audible click provides clinicians with confirmation that the de-accessed needle is in its locked safety position. The GRIPPER PLUS Safety Needle is safe for clinicians, comfortable for patients, and easy to use. It also allows institutions to comply with NIOSH / CDC criteria for sharps safety.

The GRIPPER PLUS Safety Needle is based on the input of many clinicians and the design of the familiar GRIPPER Huber needles, which are recognized as the gold standard in Huber needles. In the last five years, Deltec has sold over 10 million GRIPPER needles worldwide.

1: From behind the GRIPPER PLUS Safety Needle place fingers on each side of the base to stabilize it. With the other hand, place a finger on the tip of the safety arm. 2: Begin to lift the safety arm straight back. Notice that the needle comes out perfectly straight.

3: Continue lifting the safety arm until the needle "clicks" into the lock position. It is now safely out of the way, ready to be disposed of in a sharps container. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

LifeGuard's needle trap fully encapsulates the needle upon de-access. Compared to traditional needles and sharps, Lifeguard is designed for maximum control and safety with minor changes to technique.

Safeguard against Needlestick injuries

Enhanced for Patient Comfort

Designed for Maximum Control

Easy to Use

Minimum change to technique

Large Grip Handle for Secure control

LifeGuard features:

Visual and audible confirmation of safety

Colored safety handle for needle gauge confirmation

Low profile design

Height adjustable wings

Needleless compatibility

Easy to secure

LifeGuard Safety Needle will easily insert into all implanted ports and when de-accessing from the port it encapsulates the sharp point fully, preventing unnecessary needlesticks to clinicians and custodial staff.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Whether you're delivering chemotherapy, antibiotic therapy, or parenteral nutrition, the Surecan Safety Huber Needle's patented safety clip will automatically engage as you withdraw the needle from the base plate.

That's safety and compliance virtually assured.

SURECAN Safety Huber Needle Features:

Passive design - no user activation needed

Enables you to inject medication or withdraw blood from the Y-site with a simple luer connection when using available ULTRASITE Needle-free valve

DEHP-free for compatibility with chemo drugs and lipids

Latex-free to avoid the risk of allergic reaction

Conveniently color-coded by size (19, 20, and 22 gauge)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Simple to use

Robust safety mechanismEasy visibility of access siteSmall footprintNon-absorbent patient comfort padNon-coring needleLatex freeBest overall value

SafeStep Huber Needle Set combines excellent safety Huber needle technologan affordable, simple to use product. SafeStep features ay in robust safety mechanism with a clear base for easy site visibility. It boasts a small footprint, one of the smallest available today! Its patient comfort pad is soft and supple for patient comfort during infusion. SafeStep is the best overall value for you, your nurses, and your patients!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~MiniLoc Safety Infusion Set is Specialized Health Products premier safety Huber needle. MiniLoc is designed with an ultra-low profile, small footprint and enhanced angled tubing to facilitate dressing and help maintain dressing integrity.

MiniLocs specially lubricated needle reduces penetration and access forces during port access. Its needle forward design facilitates dual lumen port access. MiniLoc is latex free and features DEHP free tubing. MiniLocs ergonomic, integral wing design allows controlled, easy safety mechanism engagement. An audible click as well as tactile feel and a visual indicator confirm safety mechanism engagement

http://www.isips.org/Safety_Huber_Needle.phpLet's Learn ABG's ~ Part I

Normal pH of the blood is 7.35 to 7.45

Look at pH and determine if it is acidotic or alkalotic > 7.45

The pH is the best overall indicator in determining the acid-base status of the patient.

Both acidosis and alkalosis can be of two different types: respiratory and metabolic.

Respiratory acidosis or alkalosis is caused by various malfunctions of the lungs.

Metabolic acidosis or alkalosis is caused by various metabolic disorders which result in an excessive build up or loss of acids or bases.

Ok heres my basic first step interpretation:

Ph interpretation.

If Ph < 7.35, aciDotic. ( "D" for down, or less then).

If Ph > 7.45, alKalotic ( "K" for Clouds, up, or greater then -- hey its close!)

Bicarb is kidneys, metabolic. ( 22-26) PCo2 is lungs, respiratory. (35-45, same as the ph)

Put them together, you get your answer :)

The end!

You got the Ph, right??If its low, you're acidotic.If its high, your alkalotic.

Now we need to figure out if its respiratory, or metabolic. So we look at the bicarb and the PCo2.

If the Pc02 is normal ( 35-45), then it cannot be a respiratory problem. If the Pc02 is above or below normal, its a respiratory problem.

If the bicarb is normal (22-26), then it cannot be a metabolic problem.if the bicarb is above or below normal, it is a metabolic problem.

So the first part:

Metabolic or Respiratory.

** We look at the bicarb and the PCo2. Which one is out of range?

Now the second part:

** We look at the PH:Is the Ph high, or low? That gives you the answer to that.

Then, we combine the two to get the answer.

Resp or MetaAcid or Alka______________________________________________________________

Basic Geriatric Respiratory Assessment

The objective of the pulmonary assessment of a geriatric patient is to check for the following:

Quality of respiratory efficiency;

Gas exchange; and

Presence of disease.

Respiratory RateNormal respiratory rates for older patients are 12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care.

Tachypnea. A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a nursing home) indicates tachypnea. In such cases, look for the following:

Infection (especially pneumonia);

COPD, the patient has air trapping and cannot empty the lungs.

Congestive heart failure

Pulmonary embolus

Metabolic acidosis.

BradypneaBradypnea is a form of hypoventilation, in which the patient has a respiratory rate of less than 10 breaths per minute.

Respiratory EffortNormal breathing is quiet and unlabored. If it is labored, it is important to note respiratory effort. In patients with pneumonia or acute abdomen, labored breathing prevents airway closure. Patients who have air hunger will often breathe with an open mouth.

Audible Breath SoundsPay attention to the breath sounds. Wheezing is an important clue to reactive airways or local obstruction. Coughing indicates lower airway irritation. Stridor implies partial airway obstruction.

Respiratory PatternsCheck for respiratory patterns and signs that indicate specific conditions. For example, inspiration interrupted by cough suggests pleuritic pain or inflammation.

Chest Movement During RespirationThe next part of the chest inspection is to observe the patient's chest movement during respiration.

Use of Accessory MusclesUsing accessory muscles implies that the forced expiratory volume is decreased to 30% of normal. In such cases, a sitting patient may lean forward with hands propped on the knees.

PercussionMake sure your hands are warm before you begin percussion. Start at the back and check each side to compare the quality of the sensation. It is key to keep the wrist loose and the hand floppy. As you percuss, consider the characteristic of the structure you are percussing. One trick is to practice over a table percussing from the center toward the legs. Notice how the percussion note feels firm when over the leg of the table. Close your eyes and practice until you can reliably stop over the leg. Sometimes an elderly patient is too ill to sit up and percussion must be accomplished with the patient in the lateral decubitus position. This position can add some artifacts of lung compression, producing dullness in the mid lung fields of both the dependent and upward lungs. Of note, the feel of the resonance may be more sensitive than the sound of the percussion note, especially in a noisy setting such as a crowded emergency room, where subtleties of sound are more difficult to appreciate.

Basic Percussion Techniques

1. Light pat. Gently pat the back on each side starting at the apices and moving down to the diaphragm.

2. Direct percussion. Place your dominant hand on the skin and raise your forefinger and tap on the skin directly.

3. Indirect percussion Place your non-dominant hand on the skin and with your dominant middle finger tap the middle finger of your nondominant hand at the sistal interphalangeal joint.

Dullness and Its Indications Dullness to percussion implies consolidation, pleural fluid, or pleural scarring.

Auscultation Make sure that the listening area is quiet, and importantly, do not listen through the patient's clothing. Warm your stethoscope either by carrying it in your pants pocket or by vigorously rubbing it. One strategy is to place a rubber membrane on the bell and have the patient breath deeply with the mouth open. Make sure that your stethoscope bell is securely placed flat on the chest and that you are not breathing on your tubing. In fact, breathe on the tubing beforehand to appreciate the low-pitched rustling sound your breath produces. Be sure that your earpieces are securely in your ears to exclude environmental noise. Listen to at least 2 respiratory cycles at each location. All breath sounds should increase in pitch with inspiration and decrease with expiration.

Begin at the bases and work up the back. Starting at the bases allows you to appreciate any basilar crackles secondary to atelectasis or early congestive heart failure. If you start at the apices and work down, such crackles might disappear by the time you get to the bases. If you hear additional noises make sure they are coming from the patient's chest and not from the skin, muscles, or other extraneous source. For example, body hair can produce a crackling sound that resembles dry cellophane crackles.

WheezesWheezes are musical sounds that indicate airway obstruction, which when it occurs during expiration, suggests a source within the chest. Wheezing that occurs on inspiration suggests obstruction in the trachea (outside the chest). Hearing both inspiratory and expiratory wheezes is more concerning than hearing either alone.

Crackles (Rales)Inspiratory crackles are common in elderly people. Note the location of expiratory crackles. Fixed crackles suggest fibrosis or pneumonia.

RhonchiRhonchi are coarse flapping sounds that suggest fluid or mucus in an airway.

Pleural Friction RubsPleural friction rubs are leathery, creaky sounds similar to the sound of slowly rubbing your palms together. They do not have a musical quality, like a wheeze does, but suggest 2 inflamed pleural surfaces rubbing together. They can occur on both inspiration and expiration, but they usually occur with inspiration and tend to be localized. Hearing a pleural friction rub implies neoplasm, pulmonary infarction, pneumonia or tuberculosis.

Signs of Pleural InflammationPain offers a clue to possible pleuritic inflammation. Pain from pleural irritation may also be referred to the shoulder.

Demeanor and Posture Patients in respiratory distress may appear restless, agitated, or drowsy. The patient's eyes may be prominent. Patients in respiratory distress will often sit leaning forward using their accessory muscles. Patients who sit leaning forward with their legs dependent (Fowler's position) may have severe heart failure.

Informed ConsentInformed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.

In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

The patient's diagnosis, if known;

The nature and purpose of a proposed treatment or procedure;

The risks and benefits of a proposed treatment or procedure;

Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

The risks and benefits of the alternative treatment or procedure; and

The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states. Providing the patient relevant information has long been a physician's ethical obligation, but the legal concept of informed consent itself is recent.

The first case defining informed consent appeared in the late 1950's. Earlier consent cases were based in the tort of battery, under which liability is imposed for unpermitted touching. Though battery claims occasionally occur when treatment is provided without consent, most consent cases generally center around whether the consent was "informed", i.e., whether the patient was given sufficient information to make a decision regarding his or her body and health care.

It is important that the communications process itself be documented. Good documentation can serve as evidence in a court of the law that the process indeed took place. A timely and thorough documentation in the patient's chart by the physician providing the treatment and/or performing the procedure can be a strong piece of evidence that the physician engaged the patient in an appropriate discussion. A well-designed, signed informed consent form may also be useful, but an overly broad or highly detailed form actually can work against you. Forms that serve mainly to satisfy all legal requirements (stating for example that "all material risks have been explained to me") may not preclude a patient from asserting that the actual disclosure did not include risks that the patient unfortunately discovered after treatment.

At the other extreme, listing all of the risks may not be wise either. A comprehensive listing will be difficult for the patient to understand and any omission from the list will likely be presumed undisclosed. Medicare participating physicians must also be cognizant of CMS's requirements for informed consent.

________________________________________

When you find a pill lying about, or in an unmarked container, try this site for pill ID:

www.pharmer.org Righthand side, best resources in the NAVIGATION brown box. You land on other sites, but the drug.com pill wizard is fantastic.

www.epocrates.com has my fav free drug guide and compatability stuff online or PDA/Blackberry, but not all options are free.

And for my 'Como se dice esto en Espanol' issues, I like www.freetranslation.comEncyclopedia of Nursing and Allied Health

This is probably more of a resource for students, but is jam packed with useful information for all.

http://www.enotes.com/nursing-encyclopedia/Insulin Chart ~ Types, Onset, Peaks, and Durations

Types of Insulin

Each type of insulin has an onset, a peak, and a duration time.The onset is how soon the insulin starts to lower your blood glucose after you take it.The peak is the time the insulin is working the hardest to lower your blood glucose.The duration is how long the insulin laststhe length of time it keeps lowering your blood glucose.

http://diabetes.niddk.nih.gov/dm/pub...z/insert_C.htmEat Right - Printable Patient Handouts

The American dietetic association.The ADA Nutrition Care Manual is a valuable resource providing disease-specific information and evaluation, printable patient handouts, calculators that compute BMI/weight range, customization tools and much more.

http://www.eatright.org/cps/rde/xchg...xsl/index.htmlThe Land of ABG *

A. The Last Name 1. First, look at her pH. (Normal = 7.35-7.45) 2. If her pH is < (less than) 7.35; her last name is ACIDOSIS. 3. If her pH is > (greater than) 7.45; her last name is ALKALOSIS. (Note: To be an absolutely perfect last name--her pH needs to be 7.40. So, keep in mind, that if her pH is 7.35-7.39--shes thinking about marrying into the ACIDOSIS family. If her pH is 7.41-7.45--shes thinking about marrying into the ALKALOSIS family.)

B. The First Name Now that you know your patients last name, you would like to also learn her first name. 1. Look at her pH again. 2. If it is 7.35-7.45 (normal) then her first name is COMPENSATED. 3. If the pH is 7.45--then her first name is UNCOMPENSATED.

C. The Middle Name Now that you know your patients first and last name, you would like to know her middle name. (Name Alert: These people are all related and you have many patients with the same first and last name. A middle name will give you more information to go on.)

1. First you need to look at the CO2 and HCO3. (Remember: Normal CO2 = 35-45. Normal HCO3 = 22-26) 2. The middle name will either be Respiratory or Metabolic. 3. If the CO2 is 45--her middle name is RESPIRATORY. 4. If the HCO3 is 26--her middle name is METABOLIC.

D. The Family Feud 1. pH and HCO3 are "kissin cousins"--they like to go in the same direction. 2. But CO2 is the "black sheep"--pH runs the opposite direction when it sees him coming. Therefore: 3. Decreased pH with Decreased HCO3 = ACIDOSIS. 4. Increased pH with Increased HCO3 = ALKALOSIS. 5. Decreased pH with Increased CO2 = ACIDOSIS. 6. Increased pH with Decreased CO2 = ALKALOSIS.

http://realnurseed.com/abg.htmPeds Quiz ~ 25 questions/Instant Scoring

Click this link to take the test live:

http://www.peppsite.com/course_pretesting_als.cfm

1.A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.

You should immediately determine whether the patient has:

A.stridor.B.delayed capillary refill time.C.weak pulses.D.the ability to tolerate oral feedings.


Abdominal breathing in this patient should be viewed as a:

A.normal finding for a toddler.B.sign of impending respiratory failure.C.sign of decreased perfusion to the respiratory center.D.compensatory mechanism to increase the volume of air inhaled and respiratory rate.


The first step in treatment is to:

A.administer a nebulizer treatment with a beta-agonist medication.B.administer humidified oxygen via blow-by method.C.suction the oropharynx for secretion.D.deliver bag-valve-mask ventilations.

4.A 6-year-old boy who was struck by a car while he was riding his bicycle is unresponsive and has pale, cool skin. Assessment reveals abrasions to his left shoulder and back and a swollen, deformed left thigh. He has a blood pressure of 74/62 mm Hg, a pulse of 152 beats/min, and respirations of 44 breaths/min. without increased work of breathing. What do these findings tell you about the patient s condition?

A.He is unresponsive and his skin is cool because of a low body temperature from being outsideB.His heart rate is fast because of pain in his shoulder and legC.His respirations are fast because the impact affected the respiratory center in his brainD.His blood pressure is low because compensatory mechanisms for blood loss are failing

5.A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min.

The tachycardia in this infant is most likely due to:

A.anxiety.B.hypovolemia.C.pneumothorax.D.swelling of the brain.

6.A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min.

The appropriate initial treatment is to:

A.administer 100% oxygen by mask.B.administer dopamine intravenously.C.administer epinephrine via an intraosseous needle.D.perform endotracheal intubation.

7.Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal seizure?

A.FeverB.Crackles in the lungsC.Abdominal tendernessD.Cardiac dysrhythmia

8.Activated charcoal is contraindicated in a patient who has ingested a toxic substance if:

A.there is a history of abdominal surgery.B.there is a history of diarrhea or vomiting.C.the substance was corrosive.D.the substance was ingested approximately one hour ago.

9.A 10-year-old girl is unresponsive when she surfaces after diving into a quarry. Bystanders report that she was shaking all over as they pulled her out of the water. The first step in caring for this patient is to:

A.stabilize her cervical spine to reduce the risk of further spinal injury.B.elevate her head to reduce the risk of aspiration.C.turn her on her side to allow any water to drain from her mouth.D.open her mouth and insert an oropharyngeal airway to maintain a patent airway.

10.An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min.

What is the best approach to conducting the assessment of this patient?

A.Telling him he must lie still or he may become paralyzedB.Exposing only those areas currently being assessed and then covering themC.Asking him if it is okay to listen to his lungs and touch his chest and stomachD.Asking him what hurts the most and begin by assessing that area of the body


After completing your initial assessment, the first step in caring for this patient is to:

A.manually stabilize the cervical spine to reduce the risk of spinal injury.B.initiate hyperventilation to reduce the accumulation of acids in the body.C.cover him with blankets to prevent heat loss.D.place him in a position of comfort to decrease anxiety.


What is the most likely cause for the abnormal appearance of this patient?

A.Secondary brain injuryB.HypoxiaC.PainD.Hypothermia

13.What information is important to obtain about a child with smoke inhalation?

A.Presence of windows or ventilation in the roomB.Position of the patient when foundC.History of recent cold symptomsD.Location in the room where the patient was found

14.A 6-month-old infant who is being cared for by a babysitter is unresponsive and has warm, pink skin and respirations without increased work of breathing.. The babysitter appears anxious and frustrated and explains that the infant had been crying for hours and would not stop. The babysitter states, "I couldn t get her to stop crying. I tried everything. All of a sudden she got really quiet, and I couldn't wake her up. Please help her. I can't take her crying any more." The babysitter states that she does not think that the infant has been sick recently. The infant s altered level of consciousness is most likely due to:

A.toxic exposure.B.shaken baby syndrome.C.seizures.D.respiratory failure.

15.An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right, according to his caregivers. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is the best way to interact with the caregivers?

A.Confront them by telling them you know that this injury could not have occurred from a fall; therefore, you are obligated to take him to the hospital.B.Ask them why they waited so long to call for help; the delay has made the child very sick; therefore, you will need to administer oxygen and establish an IV.C.Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child.D.Explain that you are very concerned about the child s condition and that he needs to be examined at the hospital for a possible a broken leg.

16.A woman who is about to deliver a baby at home reports that the fluid was thick green when her bag of waters broke. The most important treatment of the newborn is to:

A.vigorously dry and warm the baby.B.copiously suction the mouth and nose.C.administer oxygen by nasal cannula at 4 L/min.D.calculate the APGAR score.

17.Ascertaining the due date of a newborn during an impending delivery helps you to:

A.assemble the correct size of equipment to care for the baby.B.decide whether the baby will be delivered at the scene or if there is time to transport the mother to the hospital.C.decide if an on-scene delivery is needed, particularly if the infant is premature, as the labor is often shorter for these infants.D.determine if meconium aspiration may have occurred.

18.Assessment of a newborn five minutes after delivery reveals cyanosis of the hands, feet, trunk, and face. Vital signs are pulse 160 beats/min and respirations 44 breaths/min. Treatment of this newborn includes:

A.initiating bag-valve-mask ventilations.B.performing intubation and positive pressure ventilation.C.applying free flow oxygen by mask at 5 L/min.D.reassessing the skin color in five minutes and then initiating oxygen therapy if needed.

19.An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present?

A.Use of abdominal muscles to breatheB.Temperature of 37 degrees (98.6 F)C.Acting fussier than normalD.Refuses a pacifier

20.A 3-year-old boy who has a tracheostomy has had difficulty breathing and coughing for 2 days because of increased secretions. He is on continuous oxygen. His mother states that his breathing is getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious secretions in the tracheostomy tube. Which of the following signs suggests significant obstruction of the tracheostomy tube?

A.A slow heart rate and poor air exchangeB.Irregular respirations and wheezingC.Crackles and decreased breath soundsD.Unequal chest rise and wheezing

21.During transport, what is the correct way to manage the respiratory status of a boy who is on a ventilator but also breathes on his own?

A.Allow the patient to remain on the ventilator if he is not in respiratory distressB.Immediately deliver bag-valve-mask ventilations because you may not be familiar with the ventilatorC.Switch the patient to oxygen by blow-by method because the ventilator will not work in the ambulanceD.Decrease the flow rate as the oxygen in the ambulance is more potent and requires a lower flow rate

22.What is the danger of using a mask that is too large on a child who requires ventilatory assistance?

A.Eye injuries may occur from the mask touching the globeB.It will be more difficult to obtain a seal for ventilationC.More pressure will need to be applied to obtain a mask seal, which may cause dislocation of the mandibleD.If the mask extends across the eyes, it may exert pressure and stimulate the vagus nerve

23.What is the correct method to confirm proper placement of an endotracheal tube?

A.Palpate for chest rise and fall over the anterior chest and abdomenB.Observe for gastric distention which indicates leakage of air around the tube in the tracheaC.Auscultate the anterior chest and mid-abdominal area for the presence of bubbling or gurgling soundsD.Auscultate for bubbling or gurgling sounds over the epigastrium and breath sounds at the midaxillary regions

24.When should the child s head be secured to the spine board during the immobilization procedure?

A.After the body straps and lateral stabilization devices have been appliedB.After the body straps have been applied, but before the lateral stabilization devices to ensure that the tape is applied tightlyC.Before any straps or lateral stabilization devices have been appliedD.If the child is quiet the head does not need to be secured once lateral stabilization devices are applied

25.Which of the following substances can be infused via an intraosseous needle?

A.All medications and intravenous fluidsB.All medications except sodium bicarbonate and dextroseC.Fluids or medications that are not acidicD.Only medications and fluids that have a neutral pH

__________________________________

CDC - Infectious Disease Guidelines

Topic SectionsAntibiotic and antimicrobial resistance

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_bacterial.htm" \t "_blank" Bacterial infections

INCLUDEPICTURE "http://www.cdc.gov/ncidod/images/right_tri_dark_blue.gif" \* MERGEFORMATINET

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_diarrheal.htm" \t "_blank" Diarrheal diseases

Infection control, healthcare quality, and healthcare-related infections (on Division of Healthcare Quality Promotion site)

HYPERLINK "http://www.cdc.gov/ncidod/hip/Occhealt/ocguide.htm" \t "_blank" Occupational exposure and health (on Division of Healthcare Quality Promotion site)

Opportunistic infections

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_parasitic.htm" \t "_blank" Parasitic infections

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_std.htm" \t "_blank" Sexually transmitted diseases

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_surveillance.htm" \t "_blank" Surveillance

Travel and immigrationNote: for SARS-related guidelines, please see the Severe Acute Respiratory Syndrome siteVaccination

INCLUDEPICTURE "http://www.cdc.gov/ncidod/images/right_tri_dark_blue.gif" \* MERGEFORMATINET

HYPERLINK "http://www.cdc.gov/ncidod/guidelines/guidelines_topic_viral.htm" \t "_blank" Viral infectionshttp://www.cdc.gov/ncidod/guidelines...ines_topic.htmECG ~ 6 Second Strips

Challenge yourself to identify rhythm strips

http://www.medi-smart.com/tut-15.htmECG Encyclopedia

EKG Encyclopedia:

http://sprojects.mmi.mcgill.ca/heart/egcyhome.htmlThe Virtual Pediatric Patient

Available Cases

Case 1 - A cranky child

Case 2 - A child with an abdominal mass

Case 3 - An adolescent with leg pain

Case 4 - A child with chronic constipation and pica

Case 5 - A child with vomiting and diarrhea (Note this case is only available to users at the University of Iowa)

Case 6 - A child with a sore throat

Case 7 - A child with a fever

Case 8 - A newborn with vomiting

http://www.virtualpediatrichospital....dsVPHome.shtmlThe Virtual Autopsy

Ever had the urge to be a Medical Examiner? This site gives you 12 cases, their medical history & exam results ~ You try to pinpoint the cause of death.

http://www.medi-smart.com/tut-40.htmTraumatic Brain Injury Simulator

The Neurotrauma Moulage is a traumatic brain injury simulator. It is designed to simulate a range of conditions affecting the management of the injured brain, and to encourage a greater understanding of the main tenets of traumatic brain injury management - especially the prevention of secondary injury. The initial stages of the moulage take you through the acute, emergency department management of the head injured patient. Once on the intensive care unit you are faced with various scenarios and you have to act to minimise brain ischaemia. You will not be presented with the next scenario until you've managed to get the brain back to it's calm, blue, oxygenated state as in the picture below!

http://www.medi-smart.com/tut-38.htmECG Workshop

ECG ROUNDS:Choose a case below

CaseDescriptionA 75 year old man with dyspnea. What is the diagnosis?

A 43 year old man with atypical chest pains. What is the diagnosis?

A 58 year old female with chest pains. What is the diagnosis?

A 75 year old woman with new onset of palpitations. What is the rhythm?

A patient with chest pain and dyspnea. What is the rhythm?

An elderly man with stroke. What interesting phenomena occurs?

Chest pain while visiting in the hospital. What's the diagnosis?

Anorexia and dehydration. The EKG makes the diagnosis.

Lidocaine may be hazardous to your health.

A case of abnormal complexes.

A 36 year old female with dyspnea after cocaine. What's the rhythm?

A 29 year old female with palpitations. What's the rhythm?

A 27 year old male with chest pain. What's the diagnosis?

Is it ventricular or atrial?

Interesting Rhythm and complexes.

52 yo male c/o chest pain.

74 y.o. male c/o weakness and dyspnea.

http://www.mdchoice.com/EKG/ekg.aspOrientation to ICU/CCU

We wrote this book to help new nurses and those orienting to ICU. They liked it so much they encouraged us to put it online for others to use...feel free to use these materials, but please give us attribution. Enjoy... feel free to copy them for any useful purpose. Thanks! http://www.icufaqs.org/ [email protected]

HYPERLINK "http://www.icufaqs.org/NewInICU.doc" \t "_blank" Starting Out - New in the ICU

HYPERLINK "http://www.icufaqs.org/LabsUpdated.doc" \t "_blank" Labs

HYPERLINK "http://www.icufaqs.org/PressorUpdate.doc" \t "_blank" Pressors and Vasoactives

HYPERLINK "http://www.icufaqs.org/Pacemakers.doc" \t "_blank" Pacemakers

HYPERLINK "http://www.icufaqs.org/MedTips.doc" \t "_blank" Med Tips

HYPERLINK "http://www.icufaqs.org/ArrhythmiaReview.doc" \t "_blank" Arryhthmia Review

HYPERLINK "http://www.icufaqs.org/ChestTubes.doc" \t "_blank" Chest Tubes

HYPERLINK "http://www.icufaqs.org/BlindSuctioning.doc" \t "_blank" Blind Suctioning for Beginners

HYPERLINK "http://www.icufaqs.org/x-rayfilescombined.doc" \t "_blank" Reading X-rays

HYPERLINK "http://www.icufaqs.org/PeripheralIVs.doc" \t "_blank" Perhipheral IV's for Beginners

HYPERLINK "http://www.icufaqs.org/IntubationFAQ.doc" \t "_blank" Intubations

HYPERLINK "http://www.icufaqs.org/NGtubes.doc" \t "_blank" NG Tubes for Beginners

HYPERLINK "http://www.icufaqs.org/ventFAQ.doc" \t "_blank" Vents and ABGs

HYPERLINK "http://www.icufaqs.org/FoleyCatheters.doc" \t "_blank" Foleys for Beginners

HYPERLINK "http://www.icufaqs.org/PulmonaryEmbolism.doc" \t "_blank" Pulmonary EmbolismsICP Monitoring

HYPERLINK "http://www.icufaqs.org/BloodUpdated.doc" \t "_blank" Transfusions and Blood

HYPERLINK "http://www.icufaqs.org/Newestarticle.doc" \t "_blank" Two Interesting Situations

HYPERLINK "http://www.icufaqs.org/PALinesApril04.doc" \t "_blank" PA-Lines

HYPERLINK "http://www.icufaqs.org/Defibrillation.doc" \t "_blank" Defibrillation

HYPERLINK "http://www.icufaqs.org/BedsideEmergencies.doc" \t "_blank" Bedside Emergencies

HYPERLINK "http://www.icufaqs.org/LastHeartBlock.doc" \t "_blank" Heart Blocks

HYPERLINK "http://www.allnursesunite.com/forum/ekgs2.doc" \t "_blank" Reading EKGs II

HYPERLINK "http://www.icufaqs.org/narrative.doc" \t "_blank" What

HYPERLINK "http://www.icufaqs.org/narrative.doc" \t "_blank" Nurses

HYPERLINK "http://www.icufaqs.org/narrative.doc" \t "_blank" Really Do...

HYPERLINK "http://www.icufaqs.org/ArterialLines.doc" \t "_blank" Arterial Lines

HYPERLINK "http://www.icufaqs.org/finalsedationupdate.doc" \t "_blank" Sedation and Paralysis

HYPERLINK "http://www.icufaqs.org/CentralLines.doc" \t "_blank" Central Lines

HYPERLINK "http://www.icufaqs.org/ReadingEKGs.doc" \t "_blank" Reading 12-lead EKGs

HYPERLINK "http://www.icufaqs.org/IABPFAQ.doc" \t "_blank" IABP Review

HYPERLINK "http://www.icufaqs.org/Nutrition.doc" \t "_blank" Nutrition

http://www.icufaqs.org/Help Calculating Medication Dosages - Includes test with instant scoring

Calculating Medication Dosages

This interactive study guide features Learning Outcomes, Matching Questions, Practice Questions, Know Your Labels, Case Studies, Student Success, a Link to the New York Times, and WebLinks, which will help you apply the concepts presen

77462739-Nclex-Study-Content-Use.doc

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